OVERVIEW
A series of neurologic symptoms caused by ischemia of the vertebrobasilar system, mainly characterized by recurrent episodes of vertigo, limb weakness, double vision, unsteady walking, etc. Atherosclerosis, cervical spondylosis, cardiac disease, microembolism, etc., are treated with medication and interventional therapy.
Definition
Vertebrobasilar artery insufficiency is a series of neurological dysfunctions due to blood supply disorders in the vertebrobasilar system caused by cerebral atherosclerosis, cervical spondylosis, and heart disease.
The vertebrobasilar system includes vertebral arteries, basilar arteries, and posterior cerebral arteries, which are also known as the posterior circulatory system.
Inadequate blood supply to the vertebrobasilar arteries can affect the neurological function of the brainstem, cerebellum, thalamus, occipital lobe, part of the temporal lobe and the upper spinal cord.
It often manifests as recurrent vertigo, vomiting, double vision, visual field defects, unclear articulation, dysphagia, limb weakness, and unsteady walking.
Pathogenesis
Vertebrobasilar insufficiency is a common clinical condition, but there are no authoritative morbidity data.
Vertebrobasilar artery blood supply insufficiency can cause acute posterior circulation ischemic stroke, with 18 new cases per 100,000 people per year [1].
Etiology
Causes
The causes of vertebrobasilar insufficiency have not been fully elucidated, but are currently thought to be related to the following factors.
Atherosclerosis: Long-term smoking, alcohol consumption, and hyperlipidemia can lead to endothelial damage and lipid deposition in the arteries, causing atherosclerosis, resulting in narrowing of the lumen of the vertebrobasilar arteries and insufficient blood supply.
Microembolism: Microthrombi or microemboli shed by atherosclerosis can block the vertebrobasilar artery system, causing transient or sustained ischemia and infarction of brain tissue.
Cervical vertebral bone lesions: lesions such as cervical vertebral osteophytes, intervertebral disc herniation, dislocation, tuberculosis and trauma can directly compress the neighboring vertebral artery or cause reflex vasoconstriction, which narrows the lumen and causes insufficient blood supply, i.e., vertebral artery-type cervical spondylosis [2].
Other: hemodynamic changes, vasospasm, trauma, vasculitis and other conditions can cause insufficient blood supply to the vertebrobasilar artery.
Predisposing factors
The following factors can trigger the above etiologies, causing episodes or exacerbations of vertebrobasilar insufficiency.
Smoking and alcohol consumption
Prolonged smoking and drinking can damage the endothelial cells of blood vessels and cause atherosclerosis, which in turn leads to narrowing of the blood vessels in the vertebrobasilar system and insufficient blood supply.
Neck movement or position change
Sudden and extensive head rotation can aggravate vertebral artery compression and induce the disease.
Sudden changes in body position, such as standing up from a sitting or lying position, can cause rapid changes in blood pressure and trigger the disease.
Risk factors
People with any of the following risk factors are at high risk for vertebrobasilar insufficiency.
Middle-aged or elderly people.
Family history of cerebrovascular disease.
Long-term smoking, alcohol consumption, lack of exercise, high salt and high fat diet, overweight and obesity.
Suffering from hypertension, hyperlipidemia, diabetes mellitus, hyperhomocysteinemia, cervical spondylosis and so on.
Suffering from stroke, atrial fibrillation, coronary atherosclerotic heart disease, etc.
Symptoms
The clinical symptoms of vertebrobasilar insufficiency are related to the degree of stenosis of the vessel and the compensation of collateral circulation.
When the stenosis is severe and the collateral circulation is unable to compensate, non-specific symptoms of posterior circulation ischemia may occur.
Main symptoms
Dizziness and nausea
The manifestations are dizziness and inability to stand still.
The occurrence of dizziness is often associated with positional changes (including neck turning, neck flexion, neck extension, etc.).
At the same time, epigastric discomfort and vomiting are common.
Limb weakness
Weakness of the upper and lower limbs on one side, inability to hold things, inability to stand.
Sensory abnormalities
Decreased sensation in the face and limbs, decreased sensitivity to pain or hot and cold stimuli, and numbness can also occur.
Dysphagia
This is characterized by effort in swallowing, difficulty in swallowing or food regurgitation, choking and coughing after swallowing.
Dysarthria
This is characterized by difficulty in speaking, slurred and unclear pronunciation, and hoarseness.
Ataxia
Uncontrolled movement of limbs, inability to hold things, or inability to walk in a straight line, unsteady standing and gait.
Visual disturbances
Seeing things with double vision (diplopia).
Loss of vision and blurred vision.
Other
Occipital headaches and memory loss may also occur.
Complications
If combined with changes in blood flow, tiny emboli, and vasospasm, transient, reversible ischemia can result, causing a transient ischemic attack of the posterior circulatory system, also known as a vertebrobasilar system TIA.
If further acute and severe ischemia occurs, acute posterior circulation ischemic stroke is manifested.
Vertebrobasilar TIA
Sudden onset of dizziness, nausea, vomiting, falling when turning or tilting the head, and short-term memory loss.
The above symptoms usually do not last more than 1 hour, and the longest time does not exceed 24 hours and will be relieved by themselves, without sequelae, but may recur.
Acute posterior ischemic stroke
Persistent and severe symptoms such as vertigo, ataxia, quadriplegia, coma, high fever, etc., which can lead to death in critical condition.
It continues to progress for more than 24 hours and does not resolve on its own.
Consultation
Department of Medicine
Neurology
When patients experience recurrent episodes of vertigo, limb weakness, and unsteady walking, it is recommended that they seek medical attention promptly.
When a physical examination reveals insufficient blood supply to the vertebrobasilar artery, prompt medical attention is recommended.
In addition to the Department of Neurology, patients can also visit the Department of Neurosurgery, Department of Interventional Medicine, and Department of Vascular Surgery.
Emergency Department
If the patient develops symptoms such as coma, syncope, hallucinations, limb paralysis, etc., he/she should immediately consult the Emergency Department or call the 120 emergency number for emergency services.
Preparation for medical treatment
Preparation for medical consultation: registration, preparation of documents, common problems
Tips for seeking medical treatment
Before seeking medical treatment, it is recommended to rest in bed and minimize moving and activities.
Preparation Checklist
Symptom list
Time of onset of symptoms, special symptoms, etc.
Any dizziness, nausea or vomiting?
Any limb weakness, numbness, unsteady walking?
Choking on water, slurred speech, etc.?
Any memory loss?
When did the symptoms first appear and approximately how long did they last each time?
Any aggravating or relieving factors?
Medical History Checklist
Does anyone in the family have cerebrovascular disease?
Is there any chronic smoking, alcohol consumption, lack of exercise, high salt and high fat diet, obesity?
Is there hypertension, hyperlipidemia, diabetes, hyperhomocysteinemia?
Are there any diseases such as stroke, atrial fibrillation, coronary atherosclerotic heart disease?
Do you have cervical spondylosis? Is there any sudden turning of the head, change of body position, etc. before the onset of the disease?
Checklist
Examination results in the last six months, which can be brought to the doctor’s office
Imaging examination: cranial CT, MRI, cerebral angiography
Ultrasonography: transcranial Doppler, carotid ultrasonography, etc.
Laboratory tests: blood glucose, blood lipids, coagulation function, etc.
Medication list
Medications used in the last 3 months, if available in boxes or packages, carry them to the doctor’s office
Antiplatelet aggregation drugs: aspirin, clopidogrel, etc.
Lipid-lowering drugs: atorvastatin, fenofibrate, resuvastatin, etc.
Antihypertensive drugs: nifedipine, captopril, chlorosartan, irbesartan, etc.
Hypoglycemic drugs: glibenclamide, metformin, acarbose, insulin, etc.
Diagnosis
Diagnosis is based on
Medical history
Middle-aged and elderly population.
Presence of long-term smoking, alcohol consumption, lack of exercise, high salt and high fat diet, obesity.
Presence of hypertension, hyperlipidemia, diabetes mellitus, hyperhomocysteinemia, atrial fibrillation, coronary atherosclerotic heart disease, cervical spondylosis, and other diseases.
There is turning of the head, sudden change of body position before the onset of the disease.
Someone in the family has cerebrovascular disease.
Clinical manifestations
Symptoms
Presence of headache, vertigo, diplopia, visual disturbances, dysphagia/ dysarthria, limb paralysis, coma.
Physical Signs
Physicians use physical examination to understand muscle strength, skin sensation, brain nerve function, nerve reflexes, and ataxia.
Muscle strength check: Observe whether you can do movements such as lifting hands, sitting up, standing, walking, etc., and whether you need assistance.
Skin sensory examination: Slide a cotton swab over the patient’s skin or gently prick the skin with a blunt needle to assess the degree of sensory impairment based on sensitivity to sensation.
Brain nerve function examination: Cooperate with the doctor to complete a series of movements and tests such as eye movements, opening and closing the eyes, puffing up the cheeks, swallowing, etc. to determine whether the brain nerve function is impaired.
Swallowing function test: Observe whether there is choking when drinking water to assess the swallowing function.
Nerve reflex examination: Observe the contraction of forearm and thigh muscles when knocking the tendons of elbow and knee to assess whether the nerve reflex is abnormal.
Ataxia examination: Observe the accuracy and speed with which the patient accomplishes specific movements to assess whether ataxia exists. For example, the patient uses the pointer finger to point toward the doctor’s fingertips and the tip of his or her nose, or slides the heel of one side of the foot from the knee along the anterior aspect of the calf in the supine position to the foot.
Laboratory tests
Main items: blood glucose, blood lipids, homocysteine, coagulation, etc.
Purpose of examination: To detect the presence of high-risk factors, assess the overall physical condition, and help determine the treatment plan.
Common findings: Elevated blood glucose, blood lipids, homocysteine, abnormal coagulation, etc. can be detected.
Precautions: Regular checkups are required in order to monitor the body’s condition and assess the effectiveness of treatment.
Imaging
Transcranial Doppler Ultrasound (TCD)
It can observe parameters such as blood vessel lumen, wall and blood flow velocity, and is the preferred screening method for this disease.
The vertebral arteries are small and distributed in multiple segments, so ultrasound is easy to detect stenosis in the transverse foraminal segment of the vertebral arteries, while stenosis above the transverse foraminal segment is relatively difficult to visualize, and needs to be combined with other examination methods.
Ultrasonography is economical, convenient, noninvasive, and repeatable, but the results are highly dependent on the experience level of the operator [3].
Cranial magnetic resonance and angiography (MRI, MRA)
MRI can detect ischemic and infarcted lesions in the blood-supplied area of the vertebrobasilar artery, especially when acute cerebral infarction occurs.
MRA can show the lumen of arteries and dynamically display the blood flow, and is more intuitive for the display of collateral circulation.
Precautions:
MRA results may put the degree of stenosis in the large arteries and cannot determine stent restenosis.
Those who have metal implants such as dentures or cardiac stents in the body should inform the radiologist to decide whether the MRI examination can be performed according to the specific MRI machine.
Cervical CT or MRI
To detect cervical osteophytes, herniated discs, and lesions at the foramina.
Cautions: CT is radioactive and contraindicated for pregnant women; MRI is similar to cranial brain MRI.
Head and neck CT angiography (CTA)
CTA can show the size of blood vessel lumen, morphology, blood flow, wall and other characteristics, and can observe the site and degree of stenosis in multiple directions and angles.
CTA can also clearly observe the relationship between blood vessels and surrounding tissues.
Cautions: CTA has a certain degree of radioactivity, the accuracy of judgment of severe calcified stenosis is not good, and the use of contrast medium is required.
Digital Subtraction Angiography (DSA)
DSA is the current gold standard for diagnosing vascular stenosis.
It can observe the degree, location, morphology and scope of stenosis, and can dynamically observe the blood flow within the vertebrobasilar artery.
Precautions:
DSA cannot accurately visualize wall lesions such as plaque composition and wall thrombus, and is invasive.
It is usually performed in conjunction with percutaneous endovascular intervention.
Diagnostic Criteria
The diagnostic criteria for vertebrobasilar insufficiency are as follows [4]:
Rapid onset and recurrent vertigo, mainly characterized by a sense of rotation, swaying or unsteadiness in vision.
Accompanied by 1 or more symptoms of vertebrobasilar insufficiency such as occipital headache, nausea and vomiting, and unsteady walking.
Mild transient ischemic symptoms such as falls and ataxia occur.
Transcranial Doppler (TCD) examination confirms the presence of abnormal vertebrobasilar blood flow velocity.
Differential diagnosis
Vertebrobasilar insufficiency should be differentiated from conditions such as epilepsy, Meniere’s disease, and A. S. syndrome:
Epilepsy
Similarities: both may present with impaired consciousness and transient amnesia.
Differences:
Epilepsy is often accompanied by convulsions of the limbs that last for seconds to minutes and then resolve spontaneously.
Seizures may be accompanied by EEG abnormalities, and CT/MRI of the head in secondary epilepsy may reveal focal lesions.
Meniere’s disease
Similarities: both may present with vertigo and vomiting.
Differences:
Meniere’s disease is not associated with impaired consciousness or quadriplegia, each attack tends to last more than 24 hours, and there are no neurologic signs other than nystagmus.
There are no atherosclerotic manifestations on TCD examination and no brain or cerebrovascular lesions on MRI or CTA.
A.S. syndrome
Similarities: both may present with symptoms such as dizziness, fainting and loss of consciousness.
Differences:
Patients with A. S. syndrome usually have no focal neurologic signs and symptoms.
Abnormal findings are often seen on ambulatory electrocardiographic monitoring and echocardiography.There are no abnormalities of blood flow in the vertebrobasilar system on TCD, MRA, or CTA.
Treatment
Aim of treatment: delay the progress of the disease, improve the blood supply to the brain, avoid or reduce the occurrence of TIA and cerebral infarction.
Principle of treatment: drug treatment mainly, with thrombolysis, interventional therapy, a few patients can be surgical treatment.
General treatment
Bed rest: keep optimistic, ensure sleep, and the room should be quiet.
Nasogastric feeding: If unable to eat, nutritional supplements can be given via nasal feeding tube.
Airway management:
If there is coma or signs of hypoxia, oxygen can be given to assist ventilation therapy.
Turn, pat the back, and suction at regular intervals to prevent lung infection.
Appropriate fluid replacement and volume expansion can be given to patients with hypotension and hypoperfusion to maintain circulatory stability.
Drug therapy
Antiplatelet drugs
Can prevent thrombosis.
Commonly used drugs: aspirin, clopidogrel, etc.
Adverse reactions: gastrointestinal bleeding, abdominal pain, diarrhea, constipation, etc. can occur.
Lipid-lowering drugs
Can lower blood lipids, stabilize atherosclerotic plaques and reduce the risk of plaque detachment.
Commonly used drugs: atorvastatin, resuvastatin, simvastatin, etc.
Adverse effects: liver function impairment, rhabdomyolysis, etc. can occur.
Antihypertensive drugs
Applicable to patients with hypertension, can control the patient’s blood pressure.
Commonly used drugs: amlodipine, nifedipine, Benadryl, Irbesartan, etc.
Adverse effects: hypotension, electrolyte disorders, headache, etc. may occur.
Hypoglycemic drugs
Suitable for patients with diabetes mellitus, can control the patient’s blood sugar.
Commonly used drugs: insulin, metformin, acarbose, gliclazide, dagliflozin and so on.
Adverse effects: hypoglycemia, nausea, vomiting, etc. can occur.
Anti-Vertigo Drugs
Can relieve patients’ symptoms of vertigo and dizziness.
Commonly used drugs: betahistine, flunarizine and so on.
Adverse effects: drowsiness, hallucinations, mental confusion, etc.
Thrombolytic therapy
Applicable groups: patients who have acute posterior circulation cerebral infarction and are within the time window of thrombolysis.
Commonly used drugs: alteplase, urokinase, etc.
Time window: intravenous alteplase within 4.5 hours of onset, and possibly urokinase within 4.5-6 hours [5].
Precautions: use with caution in patients with bleeding or bleeding tendencies, thrombocytopenia.
Endovascular therapy (intervention)
Indications: severe stenosis of the vertebrobasilar artery system and inability to compensate for blood supply through other arterial systems.
Purpose of the procedure: to prop open the blood vessels and restore blood flow through endovascular placement of stents.
Surgical approach: mainly vertebral artery stenting [6].
Contraindications: the presence of coagulation disorders, patients with serious underlying diseases who cannot tolerate surgery and anesthesia.
Surgery
Vertebral artery cervical spondylosis
Commonly used method: anterior cervical lateral anterior decompression.
Therapeutic effect: It is to remove the protruding part, relieve its compression on the cervical nerves and blood vessels, and re-establish the stability of the cervical spine.
Possible complications: Damage to the recurrent laryngeal nerve causing hoarseness, choking on drinking water or even suffocation.
Vertebral artery stenosis
The vertebral artery is deeper, the surgical approach is more traumatic and the complication rate is relatively high, it is only used as an alternative to the failure of interventional therapy.
Commonly used methods: vertebral artery endarterectomy, vertebral artery transposition, vertebral artery bypass grafting, etc. [2-6].
Possible complications: Horner’s syndrome, lymphatic fistula, laryngeal reentrant nerve injury and incision infection.
Prognosis
Cure.
The prognosis mainly depends on the control of risk factors, the degree of stenosis and cerebral blood supply.
The prognosis of less severe cases is quite good after active and standardized treatment.
If acute posterior circulation cerebral infarction is caused, the prognosis is poor, and the morbidity, mortality and disability rates are high [7-9].
Hazards
It can lead to accidental injuries, such as falls, burns, traffic accidents, etc., due to symptoms such as vertigo, blurred vision, and limb weakness.
This disease is not only easy to develop into cerebral infarction, but also may be combined with the occurrence of myocardial infarction and sudden death, these high mortality and disability rate of the disease will seriously affect the patient’s daily life and work, and bring a heavy burden to the society and family.
Daily
Daily Management
Dietary management
Balanced diet, choosing a variety of foods to achieve reasonable nutrition to ensure adequate nutrition and appropriate body weight.
Use more cooking methods with less salt and oil, such as steaming, boiling, mixing, water-skimming and simmering, which are easy to digest and absorb.
Eat more vegetables, fruits and whole grains.
Avoid foods that contain a lot of salt, such as salted meat, salted vegetables and other foods.
Avoid spicy and stimulating foods, such as chili peppers, coffee and strong tea.
For those who have difficulty swallowing, eat pureed or pasty foods.
Quit smoking and drinking.
Life management
Appropriate exercise can be performed under the guidance of physician after the disease is stabilized.
Blood pressure, blood glucose, blood fat and other indicators should be strictly controlled to reach the ideal range.
Avoid exertion and take rest.
Maintain a relaxed mood and avoid blood pressure fluctuations due to excessive emotional fluctuations.
Disease monitoring
Monitor changes in symptoms such as headache, dizziness, muscle weakness, and decreased sensation.
Daily monitoring of blood pressure and blood sugar.
Follow-up review
Non-invasive surgical treatment patients follow the doctor’s instructions for regular review, usually once every 1 to 3 months, in order to adjust the treatment program. Review items include blood lipids, blood glucose, etc., transcranial Doppler ultrasound, magnetic resonance imaging and so on.
Restenosis after intervention mainly occurs within 1 year after surgery. Patients are recommended to be followed up at 1, 3, 6, and 12 months postoperatively, and then every 6 months is recommended to assess the occurrence of restenosis [10-13].
Prevention.
Regular screening of high-risk groups and establishment of good lifestyle habits are important measures to prevent insufficient blood supply to the vertebrobasilar artery.
Low-salt and low-fat diet, quit smoking and alcohol.
Live a regular life, have enough rest, avoid overwork, and exercise regularly.
Maintain normal body weight, with body mass index (BMI) controlled at 18.5-23.9kg/m2.
Regular physical examination, monitoring blood pressure, blood glucose, blood lipids, vascular ultrasound examination, etc.
Attention should be paid to safety in daily life, avoiding sudden and vigorous activities of the head and neck to avoid causing loss of consciousness and dizziness, which can cause falls and create danger.